Body Dysmorphic Disorder (BDD) is a mental disorder defined as a preoccupation with a perceived defect in one's appearance. If a slight defect is present, which others hardly notice, then the concern is regarded as markedly excessive. In order to receive the diagnosis, the preoccupation must cause significant distress or impairment in one's occupational or social functioning.
An Italian doctor, Morselli, first coined the term dysmorphophobia in 1886 from "dysmorph" a Greek word meaning misshapen. It was subsequently renamed Body Dysmorphic Disorder by the American psychiatric classification. Freud described a patient whom he called the "Wolf man" who had classical symptoms of BDD. The patient believed that his nose was so ugly that he avoided all public life and work. The media sometimes refer to BDD as "Imagined Ugliness Syndrome". This probably isn't particularly helpful, as the ugliness is very real to the individual concerned.
The degree of handicap varies so that some people will acknowledge that they may be blowing things out of all proportion. Others are so firmly convinced about their defect that they are regarded as having a delusion. Whatever the degree of insight into their condition, sufferers often realize that others think their appearance to be "normal" and have been told so many times. They usually distort these comments to fit in with their views (for example, "They only say I'm normal to be nice to me" or "They say it to stop me being upset"). Alternatively they may firmly remember one critical comment about their appearance and dismiss 100 other comments that are neutral or complimentary.
What are the most common complaints in BDD?
Most sufferers are preoccupied with some aspect of their face and often focus on several body parts. The most common complaints concern the face, namely the nose, the hair, the skin, the eyes, the chin, or the lips. Typical concerns are perceived or slight flaws on the face or head, such as hair thinning, acne, wrinkles, scars, vascular markings, paleness or redness of the complexion or excessive hair. Sufferers may be concerned about a lack of symmetry, or feel that something is too big or swollen or too small, or that it is out of proportion to the rest of the body. Any part of the body may however be involved in BDD including the breasts, genitals, buttocks, tummy, hands, feet, legs, hips, overall body size, body build or muscle bulk. Although the complaint is sometimes specific "My nose is too red and crooked"; it may also be very vague or just refer to ugliness.
When does a concern with one's appearance become BDD?
Many people are concerned to a greater or lesser degree with some aspect of their appearance but to obtain a diagnosis of BDD, the preoccupation must cause significant distress or handicap in one's social, school or occupational life. Most sufferers are extremely distressed by their condition. The preoccupation is difficult to control and they spend several hours a day thinking about it. They often avoid a range of social and public situations in order to prevent themselves feeling uncomfortable. Alternatively they may enter such situations but remain very anxious and self-conscious. They may monitor and camouflage themselves excessively to hide their perceived defect by using heavy make-up, brushing their hair in a particular way, growing a beard, changing their posture, or wearing particular clothes or for example a hat. Sufferers feel compelled to repeat certain time consuming rituals such as:
- Checking their appearance either directly or in a reflective surface (for example mirrors, CDs, shop windows)
- Excessive grooming, by removing or cutting hair or combing
- Picking their skin to make it smooth
- Comparing themselves against models in magazines or television
- Dieting and excessive exercise or weight lifting
Such behaviors usually make the preoccupation worse and exacerbate depression and self-disgust. This can often lead to periods of avoidance such as covering mirrors or removing them altogether.
How common is BDD?
BDD is a hidden disorder and its incidence is unknown. The studies that have been done so far have been either too small or unreliable. The best estimate might be 1% of the population. It may be more common in women than in men in the community although clinic samples tend to have an equal proportion of men and women.
When does BDD begin?
BDD usually begins in adolescence - a time when people are generally most sensitive about their appearance. However many sufferers leave it for years before seeking help. When they do seek help through mental health professionals, they often present with other symptoms such as depression or social phobia and do not reveal their real concerns.
How disabling is BDD?
It varies from a bit to a lot. Many sufferers are single or divorced, which suggests that they find it difficult to form relationships. Some are housebound or unable to go to school. It can make regular employment or family life impossible. Those who are in regular employment or who have family responsibilities would almost certainly find life more productive and satisfying if they did not have the symptoms. The partners or families of sufferers of BDD may also become involved and suffer.